Errors during care transitions of older adults are common, costly, and sometimes lethal. A care transition is defined as the movement of a person from one healthcare setting to another and is commonly associated with adverse outcomes. The aging of the population is leading to greater reliance on care delivered in the home, the most common and poorly understood healthcare delivery setting. For unclear reasons, those who require skilled home healthcare (SHHC) services (e.g., home nursing) after hospital discharge are among those at highest risk of experiencing hospital readmission. Strategies tailored to the complexity of the hospital/SHHC transition are needed to ensure safe transitions, yet there is relatively little research to guide improvement efforts. The overall goal of the proposed study is to develop an index to be used by SHHC agencies in real time to identify and reduce potential risks to older adults' safety during hospital/SHHC transitions. SPECIFIC AIM 1: To identify potential risks to older adults' safety related to (1) information management among SHHC providers across settings, and (2) establishment of older adult, caregiver, and SHHC provider roles for execution of healthcare tasks. We will use prospective risk identification methods to identify potential risks: (a) direct observations of older adults' hospital/SHHC transition; and (b semi-structured interviews of older adults/caregivers/SHHC providers. SPECIFIC AIM 2: To develop an index that will be used by SHHC agencies in real time to identify risks to older adults' safety during hospital/SHHC transitions with regard to processes of information management and establishment of roles. Through focus groups, SHHC providers will rate each risk identified in SA1 on its importance to ensuring safety and its frequency of occurrence. SPECIFIC AIM 3: To evaluate psychometric properties of the index and ascertain feasibility of use. 3a. To evaluate index inter-rater reliability among SHHC providers and establish initial construct validity among care transitions that differ in quality. For inter-rater reliability, we wll determine the correlation between index scores calculated by pairs of SHHC providers evaluating a series of care transitions. For construct validity, we will compare index scores among cases that differ in care transition quality. 3b. To further evaluate construct validity usin a different standard and ascertain feasibility of use among SHHC providers. In a prospective sample of older adults receiving SHHC after hospital discharge, we will determine the correlation between SHHC provider-generated index scores and a general measure of patient-reported care transition quality (Care Transitions Measure, or CTM-3). The proposed study will fill critical gaps in the understanding of care transitions of older adults who are particularly vulnerable to safety issues. Study findings have the potential for applicability to a broader group of patients who transition from hospital to home and require complex care.